Forms & Documents

Below you will find many of the forms and documents you may need.  If you don't see a form or document you need on this page, please click here to  contact us

Forms:

 Change of Status Form: To change member information such as name, coverage election(s) or termination of coverage benefits.   General Motors employees must contact the National Benefits Center at 1-(800) 489-4646. Forms must be signed by your employer prior to submission to MercyCare.

 PHI Release Form: Use when a member would like MercyCare to provide personal health information (PHI) to a third party. Examples of this would be benefits available or claims information.

 Stay Healthy Benefit Reimbursement Form: To request reimbursement for health and wellness activities.

 Stay Healthy Benefit for MercyCare Senior members

 ACH Form: To authorize MercyCare to take premiums due directly from a checking or savings account. This is limited to members who pay premiums directly to MercyCare.

 Drug Reimbursement Form*:  Use this form to request reimbursement of monies paid directly by you for prescription drugs.  Applicable coverage for co-insurance and/or co-pays will be deducted from reimbursement.

*Not all members recieve their Drug Plan benefits through MercyCare. If you are unsure, and would like to verify your prescription drug benefits, please contact your employer or MercyCare's Customer Service at 1-(800) 895-2421.

Documents: 

 Member Handbook 2013

 Member Handbook 2012

Large Group and Non Qualified Health Plans

 Certificate of Coverage-HMO

 Certificate of Coverage-EPO

 Certificate of Coverage-Plus

 Certificare of Coverage-POS

Individual Health Plans

 Certificate of Coverage - Inividual On & Off Exchange

Small Group Qualified Health Plans

  Certificate of Coverage - EPO On Exchange

   Certificate of Coverage - EPO Off Exchange

    Certificate of Coverage - HMO On Exchange

    Certificate of Coverage - HMO Off Exchange

 

 Privacy Notice

 Janesville Athletic Club membership benefits

 Rock County YMCA membership benefits

 

 


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